Provider Demographics
NPI:1164614434
Name:RICHIUSA, JUAN P (MD)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:P
Last Name:RICHIUSA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 919771
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-9771
Mailing Address - Country:US
Mailing Address - Phone:239-278-3600
Mailing Address - Fax:239-226-4650
Practice Address - Street 1:680 CENTRE ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02302-3308
Practice Address - Country:US
Practice Address - Phone:508-941-7379
Practice Address - Fax:508-941-6330
Is Sole Proprietor?:No
Enumeration Date:2007-08-10
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME114613207V00000X
MA236310207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL008606100Medicaid
FLHD579ZMedicare Oscar/Certification
MA2156687Medicaid